Supporting Utilization Management in Health Cloud

Utilization Management (UM) is a health insurance plan's process of interfacing with plan members and contracted medical providers to interpret, administer, and explain the medical policies of the health plan. Health Cloud provides objects you can use to review and evaluate medical care services, communicate about clinical policies, and help health plan members ensure they receive the right care in the right setting at the right time.

To ensure smoother collaboration between payers and providers, Health Cloud’s Utilization Management provides these capabilities:

• FHIR Da Vinci Health Record Exchange aligned APIs, deployed on MuleSoft, for uninterrupted request processing

  The Da Vinci Health Record Exchange (HRex) implementation guide (IG) is a foundational guide that defines FHIR profiles, operations, and guidance. HL7’s Da Vinci project produces standards and implementation guidelines based on HL7 FHIR to better connect payers and providers to tackle authorization requests.

• FHIR R4 aligned data model to promote interoperability, integration with external systems, and smooth information exchange.

  The utilization management data model includes standard objects and record types on standard objects. You can use these standard objects to model your organization’s work flows as you manage utilization data.

• Care Request

  Represents the general details of a care-related request including member information, admission date, decision reason, and so on. A single request can contain multiple diagnoses, services, or drugs. Care requests include prior authorization requests for drugs and services, admission notifications, concurrent review of admissions, appeals, complaints, and grievances.

• Care Request Extension

  Represents extra details for a care request such as the subscriber details for the member's health plan, home healthcare status, and ambulance transportation details.

• Care Diagnosis

  Represents the details of a diagnosis including code type, name, and description. One or more care diagnoses can be associated with a care request.

• Care Request Item

  Represents the details of a care service request, including name, modifiers, and the effective date. One or more care service requests can be associated with a care request.

• Care Request Drug

  Represents the details of a requested drug including name, strength, frequency, and instructions for administration. One or more drug requests can be associated with a care request.

• Care Request Reviewer

  Represents the details of a care request reviewer including name, reviewer type, status of the care request at the end of the review, and more. A care request, care request item, care request drug, or care diagnosis can be associated with a care request reviewer.

• Care Request Configuration

  Represents the details for a record type such as service request, drug request, or admission request. One or more record types can be associated with a care request.

• Care Processing Error

  Represents details about the errors that occur when processing authorization requests.

• Tracked Communication

  Represents details about the information request or communication sent from payer to provider on a member’s authorization request, such as subject, priority, status, and more.

• Tracked Communication Detail

  Represents additional information associated with Tracked Communication records such as medium of communication, recipient, and more.

• What is a Care Request?
  Care requests seek authorization from a health plan for drugs, services, and admissions. They can also contain requests for review, appeals, complaints, and grievances.
• Care Request Review Types
  Care requests can be reviewed before, during, or after the care is provided. The timing of a review can affect how you use Health Cloud to manage the process.